Tier Waiver System-
Outline of proposed changes
Outline of proposed changes
Sent: Friday, March 21, 2008 9:11 PM
Subject: FCCF - The Tiers proposed Rule
Patty Houghland
FCCF chairperson
65G-4.0021 Tier Waivers
(1) The Agency for Persons with Disabilities will assign clients of home and community-based waiver services for
persons with developmental disabilities to one of the four Tier Waivers created by section 393.0661, Florida Statues
(2007). The Agency will determine the Tier Waiver for which the client is eligible and assign the client to that waiver
based on the developmental disabilities waiver criteria and limitations provided in Chapters 393 and 409, F.S., Rule
Chapter 59G-13, F.A.C., and this rule Chapter and the Agency's evaluation of the following information:
(a) The client's level of need in functional, medical, and behavioral areas, as determined through Agency
evaluation of client characteristics, the Agency approved assessment process, and support planning information;
(b) The client's service needs as determined through the Agency's prior service authorization process to be
medically necessary;
(c) The client's age and the current living setting; and
(d) The availability of supports and services from other sources, including natural and community supports.
(2) The services described by the Developmental Disabilities Waiver Services Coverage and Limitations Handbook, July
2007 (hereinafter referred to as the "DD Handbook"), adopted by Rule 59G-13.080, F.A.C. and incorporated herein by
reference, are available to clients of the Developmental Disabilities Waiver (hereinafter called "the Tier One Waiver"),
the Developmental Disabilities Tier Two Waiver (hereinafter called "the Tier Two Waiver"), and Developmental
Disabilities Tier Three Waiver (hereinafter called "the Tier Three Waiver"). The following services described in the DD
Handbook are available to clients assigned to the Tier Four Waiver (presently known as The Family and Supported
Living Waiver):
(a) Adult Day Training;
(b) Behavior Analysis;
(c) Behavior Assistance;
(d) Consumable Medical Supplies;
(e) Durable Medical Equipment;
(f) Environmental Accessibility Adaptations;
(g) In-Home Support Service;
(h) Personal Emergency Response System;
(i) Respite Care;
(j) Support Coordination;
(k) Supported Employment;
(l) Supported Living Coaching; and
(m) Transportation.
(3) The total billings in any quarter of the state's fiscal year for any service a client is authorized to receive shall not
exceed twenty-five percent (25%) of the total annual cost plan budget for that service.
(4) For all Tiers client must utilize all available State Plan Medicaid services including, but not limited to,
personal care assistance, therapies, and medical services, that duplicate the waiver services proposed for the client. A
client shall not be provided waiver services that duplicate available State Plan Medicaid Services including, but not
limited to, personal care assistance, therapies, and medical services.
(5) The Agency will review a client's tier eligibility when a client has a significant change in circumstance or condition
that impacts on the client's health, safety, or welfare or when a change in the client's plan of care is required to avoid
institutionalization. The information identifying and documenting a significant change in circumstance or condition that
necessitates additional or different services must be submitted by the client's Waiver Support Coordinator to the
appropriate Agency Area office for determination.
(6) This rule shall take effect July 1, 2008.
65G-4.0022 Tier One Waiver.
(1) The Tier One Waiver is limited to clients that the Agency has determined meet at least one of the following criteria:
(a) The client's needs for medical or adaptive services cannot be met in Tiers Two, Three, and Four and are essential
for avoiding institutionalization, or
(b) The client possesses behavioral problems that are exceptional in intensity, duration, or frequency with resulting
service needs that cannot be met in tiers Two, Three, and Four, and the client presents a substantial risk of harm to
themselves or others.
(2) Clients living in a licensed residential facility receiving any of the following services shall be assigned to the Tier
One Waiver:
(a) Intensive behavioral residential habilitation services;
(b) Behavior focus residential habilitation services at the moderate or above level of support; or
(c) Standard residential habilitation at the extensive 1, or higher, level of support; or
(d) Special medical home care.
(3) Nursing service needs that can be met through the Tier Two, Tier Three, or Tier Four Waivers are not
"services" or "service needs" that support assignment to the Tier One Waiver.
(4) This rule shall take effect July 1, 2008.
65G-4.0023 Tier Two Waiver.
The total budget in a cost plan year for each Tier Two Waiver client shall not exceed $55,000. The Tier Two Waiver is
limited to clients who meet the following criteria:
(1) The client's service needs include placement in a licensed residential facility and authorization for greater than five
hours per day of residential habilitation services; or
(2) The client is in supported living and is authorized to receive more than six hours a day of in-home support
services.
(3) This rule shall take effect July 1, 2008.
65G-4.0024 Tier Three Waiver.
(1) The total budget in a cost plan year for each Tier Three Waiver client shall not exceed $35,000. A client must meet
at least one of the following criteria for assignment to the Tier Three Waiver:
(a) The client resides in a licensed residential facility and is not eligible for the Tier One Waiver or the Tier Two
Waiver; or
(b) The client is 21 or older, resides in their own home and receives Live-in In-Home Support Services and is
not eligible for the Tier One Waiver or the Tier Two Waiver; or
(c) The client is 21 or older and is authorized to receive Personal Care Assistance services at the moderate level of
support as defined in the DD Handbook.
(d) The client is 21 or older and is authorized to receive Skilled or Private Duty Nursing Services and not
eligible for the Tier One Waiver or the Tier Two Waiver; or
(e) The client is 22 or older and is authorized to receive services of a behavior analyst and/or a behavior
assistant.
(f) The client is under the age of 22 and authorized to receive the combined services of a behavior analyst
and/or a behavior assistant for more than 60 hours per month and is not eligible for the Tier One Waiver or the Tier
Two Waiver.
(g) The client is 21 or older and is authorized to receive at least one of the following services:
(i) Occupational Therapy; or
(ii) Physical Therapy; or
(iii) Speech Therapy; or
(iv) Respiratory Therapy.
(2) This rule shall take effect July 1, 2008.
65G-4.0025 Tier Four Waiver.
(1) The total budget in a cost plan year for each Tier Four Waiver client shall not exceed $14,792 per year.
(2) Clients who are not eligible for assignment to the Tier One Waiver, the Tier Two Waiver, or the Tier Three
Waiver shall be assigned to the Tier Four Waiver. The criteria for the Tier 4 Waiver includes, but is not limited to:
(a) Clients who are currently assigned to receive services through the Family and Supported Living Waiver unless there
is a significant change in condition or circumstance as described in section 65G-40021(4); or
(b) Clients who are under the age of 22 and residing in their own home or the family home, or
(c) Clients who are dependent children who reside in residential facilities licensed by the Department of Children and
Families under 409.175 F.S..;
(3) This rule shall take effect July 1, 2008.